also a few slightly granular and hyaline from the smaller tubes. There is yet no sign, or but faint, of broken down or degenerating cell-structure; no cloudy or compound granule-cells. This disturbance in the function of the kidneys appears at first to arise simply from impeded circulation through them, caused by the indolence of the current through the cava into which the renal veins directly empty themselves. A state of circulation through the kidneys is at first induced which materially affects the activity of the excretory function; and scanty urine, high coloured, but free from albumen, announces the embarrassment which the organ suffers. If this continue, the urine soon becomes albuminous, and the sediment of such urine usually shows the presence of coarse granular casts, without, however, any amount of renal epithelium or other condition indicative of renal degeneration. It is simply a state of albuminous urine from mechanical obstruction to the freedom of the renal circulation. It is also increased by the state of tension caused by the dropsical effusion infiltrating the tissues; for the symptoms of renal disturbance are graver in proportion to the extent and presence of the dropsical fluid. Relief is sometimes obtained by brisk hydrogogue purgatives, which by relieving tension, set free the current of blood through the kidneys, and for a time at least restore their activity. If these measures fail, if the dropsy either increases or even does not decrease, in a certain time, the urinary sediment will indicate that the renal structures are becoming disorganized. The patient up to this point may not have suffered more from the dropsical tension than what is caused by the heavy inactivity of the limbs; there may not be any inflammatory or painful distension of the cuticle; the fluid in the belly may not be sufficient to inconvenience the breathing; yet if the urinary sediment suggests by the presence of disintegrated cell-material the commencement of some organic change in the kidneys, immediate relief to the tension of the tissue must be attempted by puncturing the lower extremities. The manner of doing this is of more moment than some are inclined to think. Pricks or simple punctures with the lancet-point are not only oftentimes inefficient, but from a diffuse inflammation which sometimes follows, really injurious. Two incisions should be made, from below upwards under each internal malleolus. These should be made by a lancet being inserted up to, and even beyond its shoulders, so as to cut freely through the subcutaneous connective, or areolar tissue. The direction of the incision permits a free drain downwards of the dropsical fluid; and in the majority of cases a most effective, painless, unexhausting drain is established; the kidneys are set free, a daily augmentation in the amount of urine, accompanied by a proportionate diminution in the proportion of albumen present, testify to the relief obtained, and in some cases a permanent, and in many a most satisfactory, even though it be temporary, recovery will date from this period. The remedies of most importance at this critical period are those which assist and repair the decay, which is inevitable in any tissues, so long as they are infiltrated by dropsical fluid. The subsidence of the dropsy, even though thus artificially induced, affords a prospect of still further improvement, proportioned to the integrity and vigour of the digestive organs. It may easily be conceived that a more confident hope may be expressed of the favorable progress of those who take food without reluctance and even with appetite, and who suffer no more distress or uneasiness from flatulence while digestion is progressing, than can be expected in those whose digestive powers are weak and imperfect. Accordingly, in those ranks of life where variety of aliment can be commanded, where selection can be made governed by the judgment of the physician, or in hospital practice, where just that kind of food in quantity and quality calculated for the individual case, is appropriately ordered, the most satisfactory and favorable results are witnessed. An incontestible proof how essential, as a remediable measure, the doctrine of nutrition and support has become in these forms of disease. Whatever medicines are employed, should be auxiliary to this object; and except so far as special or occasional symptoms may require expectorants, or diuretics, or purgatives, the funda mental treatment by nutritive agencies should never be forgotten. All medicines which increase or assist the digestive function, which promote the assimilative powers, and which facilitate the formation of a purer blood, are to be preferred to those of a lowering or exhausting character, which in another generation were so fatally selected for the treatment of these dropsies. The regulation of the diet in all cases of dropsy, whether renal, pulmonary, or cardiac, is of more importance than has hitherto been conceived. The leading feature in this branch of treatment consists in the selection of those articles for food which the individual best assimilates, and which most directly influences the formation of blood. The fastidiousness of the appetite must be indulged; all slops, broths, and thin watery soups banished, and wherever possible, nutrition conveyed in the most concentrated form. The fatty elements of food should not be neglected, recognising fully the important part the fats play as agents in the conversion of animal matter into the solids of the body. If any authority beyond that of observation, or any proof beyond that of the success which attends the treatment of dropsy based on these principles were required, the authority of so distinguished a physiological chemist as Lehmann might be quoted. No animal cell and no fibre is formed independently of the presence of fat; indeed, the fat appears to possess the property of predisposing the animal organism to the formation of cells. Besides the manifold mechanical services which they render the animal organism, the fats also take part, through their chemical metamorphoses, in the most varied animal processes; and they take an active part in the process of digestion in the primæ viæ, and that they preside generally over all the processes by which the fluid nutrient substances are converted into the solid substances of organs. The formation of the colourless blood-corpuscles seems also to owe its first impulse to the metamorphosis of fat, which thus serves as the most important auxiliary in the formation of blood.* * Lehmann's 'Physiological Chemistry,' Sydenham Society edition, p. 211. 280 ON DROPSY, CONNECTED WITH DISEASE OF HEART AND LUNGS. The observations of the physiological chemist have been abundantly proved by the experience of the physician. Nutritive material selected on the principles here enumerated has repeatedly been the means of prolonging life, and even controlling and arresting the disease. The advantages of a well-regulated nutritious diet in the management of these forms of dropsy cannot, perhaps be better proved than by contrast, for far otherwise is the fate of those in another class of life whose livelihood depends on their physical powers, which are soon enfeebled and prostrated by chronic bronchitis, emphysema, or heart disease. Their condition thus aggravated by defective nourishment, scanty clothing, and, perhaps depraved and irregular habits, in these the progress of degeneration is rapid. The tissues everywhere, as in renal dropsy-slowly in some cases, more rapidly in others—lose their power of selection of nitrogenized material for the development of vigorous cell-formation. The structures insidiously, but fatally, descend in the scale of development; and tissues, the cells of which should be distinguished by a nucleus of highly nitrogenized matter, now possess but the power of abstracting hydro-carbonized products, and a fatty and amyloid degradation of cell-structure is the all-pervading pathological law-conditions which, as they proceed, give unmistakable evidence of decaying powers, and at length reach a point incommensurate with the continuance of life; and the organism which, in the fulness of its life and vigour, was but the expression of the sum of the life of its individual cells now perishes, and yields up its forces to other laws and other combinations of matter. ON DROPSY, CONNECTED WITH DISEASE OF THE LIVER. CHAPTER III. HEPATIC DROPSY.-KIDNEYS NOT NECESSARILY IMPLICATED. 281 HEPATIC DROPSY offers fewer complications for investigation than renal or cardiac dropsies. Not because diseases of other organs infrequently coexist, but because they are, for the most part, either independent of the disease of the liver or only remotely connected with it. In cases where the hepatic disease owes its origin to intemperate habits, or the pernicious abuse of alcoholic stimulants, we may not unreasonably expect indications of disease in the brain and kidneys or spleen, which, springing from the same exciting cause, have probably run their course simultaneously with the liver disorder. The affections which are chiefly developed by the hepatic disorder are those of the stomach, intestines, and peritoneum. Various forms or groups of symptoms significant of indigestion, followed by diarrhoea, and even in some cases by dysentery, arc clearly traceable to the impeded circulation and deranged function of the liver. Therefore, while disease of other great central organs may similarly exercise a disorganizing influence on the liver, as when in obstructive diseases in the chest, emphysema and dilatation of the right side of the heart, or in pneumonia or pleurisy, and particularly in advanced phthisis, the circulation through the liver is influenced by the obstruction to its free passage through the cava, and a process of disordered nutrition, followed by fatty and amyloid degeneration, is not infrequent, yet, taking the disease of the liver as the starting-point, the diseases usually subordinate to it are for the most part limited |